From the Guidelines
Rheumatoid arthritis is strongly associated with cervical spine complications, and patients should avoid chiropractic therapy due to the potential risks of exacerbating these complications. The connection between rheumatoid arthritis and the cervical spine is well-established, with the inflammatory process targeting the synovial joints and surrounding structures in the neck, particularly the atlantoaxial joint (between C1 and C2 vertebrae) 1. This inflammation can lead to ligament laxity, bone erosion, and potential instability of the cervical spine, affecting approximately 30-50% of rheumatoid arthritis patients. Patients may experience neck pain, stiffness, reduced range of motion, and neurological symptoms like numbness, weakness, or even life-threatening spinal cord compression in severe cases.
Key Considerations
- The 2023 American College of Rheumatology guideline conditionally recommends against using chiropractic therapy for rheumatoid arthritis management due to the potential cervical spine complications 1.
- Disease-modifying antirheumatic drugs (DMARDs) like methotrexate (10-25mg weekly) or biologics such as TNF inhibitors are typically used to control the underlying inflammatory disease.
- Regular radiological monitoring of the cervical spine is essential for rheumatoid arthritis patients to detect early changes and prevent serious complications.
Management and Prevention
- A combination of DMARDs, biologics, pain management, and physical therapy is often used to manage cervical spine involvement in rheumatoid arthritis patients.
- Cervical collars may provide temporary support, but surgical intervention becomes necessary when neurological deficits occur or there is significant instability.
- Patients with rheumatoid arthritis should be aware of the potential risks associated with chiropractic therapy and discuss alternative management options with their healthcare provider 1.
From the Research
Cervical Spine Involvement in Rheumatoid Arthritis
- Cervical spine instability is a significant characteristic of rheumatoid arthritis (RA), with a prevalence of 27.5% in RA patients, and can cause compressive cervical myelopathy, leading to serious neurologic sequelae 2.
- The most common type of cervical spine instability in RA patients is atlantoaxial subluxation (AAS), which is significantly associated with early initiation of biologic disease-modifying antirheumatic drug (DMARD) therapies 2.
- Risk factors for cervical spine instability in RA patients include male sex, positivity for rheumatoid factor and anti-citrullinated protein antibody (ACPA), erosive change in the peripheral joints, and presence of osteoporosis 2.
- Positivity for ACPA is the most powerful risk factor for cervical spine instability, with an odds ratio of 2.33 (95% confidence interval: 1.37,3.96), and is closely associated with AAS 2.
Radiological Evaluation of Cervical Spine Involvement
- Cervical spine involvement in RA can be evaluated using plain radiographic criteria, with the most common site affected being the atlantoaxial joint, potentially resulting in atlantoaxial instability, and the second most common site being the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression 3.
- Magnetic resonance imaging (MRI) and computed tomography (CT) can be used to assess neural element involvement and surgical planning in RA patients with cervical spine involvement 3, 4.
Clinical Manifestations and Treatment
- Cervical spine involvement in RA can manifest as atlantoaxial subluxation, retroodontoid pannus formation, cranial settling, and subaxial subluxation, with many patients being asymptomatic, but symptomatic patients often presenting with nonspecific symptoms resulting from inflammation and additional secondary symptoms due to compression of the brainstem, cranial nerves, vertebral artery, and spinal cord 4.
- Treatment of cervical spine involvement in RA includes patient education, lifestyle modification, regular radiographic follow-up, and early surgical intervention, when indicated, with the primary goal of preventing permanent neurologic injury while avoiding potentially dangerous and unnecessary surgery 5.
- Surgical management is indicated when patients experience symptoms from cervical involvement that result in biomechanical instability and/or a neurological deficit, with different surgical approaches used to manage different types of cervical spine involvement, such as atlantoaxial fusion, posterior decompression and atlantoaxial fusion or occipitocervical fusion, and circumferential fusion or posterior only decompression and fusion 4, 5.